Who

When Robert Simpson tested positive for the AIDS virus last November, medical bills were the least of his worries. As a court reporter, Simpson, 44, was earning $48,000 a year and was covered by group health insurance. In addition, he had planned ahead by buying three disability policies. Less than a year later, however, he has fallen through the widening cracks in the U.S. medical- care system. Too weak to work, he has lost the insurance coverage from his job; moreover, he has yet to see a penny from his disability policies, although he filed six months ago. "I'm just tired of being a victim," the pale, bushy-haired Simpson says slowly, pausing to gather strength in his San Francisco apartment.

Like Simpson, many of those caught up in the spiraling AIDS epidemic are awash in medical expenses they cannot afford. And the safety net beneath them has proved less than reassuring. Since the AIDS crisis began in the early 1980s, the nation's private health-care industry -- hospitals, insurance companies and pharmaceutical firms -- has engaged in quiet combat with government agencies over who should foot the bill for the disease, which now afflicts an estimated 44,000 Americans. And the tab is rising. This year the cost for AIDS medical care is expected to be $3.75 billion; by 1992 that figure is likely to more than double. Whose responsibility is it to pay for AIDS-related care? And why does American society, on the whole, seem to be shrinking from the task?

No one is rushing in to assume the financial burden. "Everyone is playing duck and cover while trying to shield themselves from the costs," observes Ronald Brunk of AIDS Benefits Counselors in San Francisco. This year federal and state programs will pay 40% of the bill, with private insurers taking care of another 40%. The remaining 20% falls in the "self pay" -- often meaning "no pay" -- category. The most important government program, Medicaid, is available only to impoverished patients. As a result, those infected with the AIDS virus frequently must "spend down" into poverty, demonstrating that they hold assets of less than $2,000. This low level of federal coverage portends future problems, since the number of people with AIDS continues to rise. "Federal health planners have been acting as if AIDS will go away," says Congressman Henry Waxman of California. "It won't."

The thicket of state insurance laws makes it possible in some cases for private insurers to find ways to keep profits up and payments for AIDS care down. In 1985 one firm, the Great Republic Insurance Co., even issued an "AIDS profile" to its agents, instructing them to treat differently applications from "single males without dependents that are engaged in occupations that do not require physical exertion." These applicants were usually denied insurance. While such major insurers as Blue Cross/Blue Shield and the Travelers deny discriminating on the basis of AIDS, others still use information about living arrangements, residences and Zip Codes to try to identify gay or bisexual men at risk for the disease. Testing applicants for the AIDS virus gives companies additional protection against insuring infected individuals who will have high medical costs. As a result, a number of jurisdictions, including Washington and the states of Florida, Maine, Wisconsin and California, have legislatively limited such testing.

Despite the substantial costs (average lifetime care for a person with AIDS: about $83,000), a fifth of those infected with the AIDS virus have no insurance at all. Increasingly, these people are flooding into overburdened public hospitals, raising fears of bankruptcies. In August the National Public Health and Hospital Institute reported that in 1987 only 5% of the nation's hospitals, most of them in inner cities, were treating 50% of the country's AIDS patients. Bellevue Hospital Center, which has one of the biggest emergency rooms in New York City, is overwhelmed to the point that care for other patients is threatened. Says Bellevue's Dr. Lewis Goldfrank: "There is going to be hospital gridlock by 1990, because there's not enough long-term, short-term or emergency-care space for AIDS patients. I think they're eventually going to fill every hospital bed in the big cities."

The stigma attached to the groups primarily afflicted by AIDS -- gays, minorities and intravenous drug users -- has unfairly limited the degree of economic assistance offered. "If this disease struck only the presidents of major corporations, the effort to evade responsibility would not have been tolerated by society," says Earl Shelp, executive director of Houston's Foundation for Interfaith Research and Ministry. Additionally, society's sense of financial obligation -- not to mention its compassion -- has been diminished by a blame-the-victim syndrome. "I think that there is a tendency to discount a situation if one feels that an infected person's condition could have been avoided," says Dr. Kathleen Nolan of the Hastings Center in Briarcliff, N.Y. Alluding to the disease's long incubation period -- frequently ten years or more -- she adds that "the vast majority of individuals who are seropositive or who have AIDS had never heard of the virus before they engaged in the behavior that resulted in their infection."

The mounting bills for AIDS patients have renewed a call in some quarters for a national medical-care system. "Optimistically, AIDS will push this country into getting universal health insurance," says New York City Health Commissioner Stephen Joseph. "Or we may be reduced to narrow-minded scrambling to see who gets what piece of the pie." However, the current budget crisis, plus resistance to socialized medicine, makes that prospect a far-off solution. In the short run, a combination of public- and private- sector responsibility, translated into cash, seems to offer the best hope for coping with this ongoing human crisis.